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Abstract

Purpose: Pediatric patients represent nearly 10 percent of all trauma admissions in major trauma centers. The study attempts to study the different patterns of demography in patients suffering from trauma to the abdomen in a tertiary care hospital in a developing nation.

Methods: The study was done in a tertiary care center over a duration of one year. The study was retrospective based on hospital records of the patients. The demographic parameters were studied and compared to available literature.

Results: A total of 288 cases of blunt trauma to the abdomen were recorded in one year. The demographic trends with respect to the etiology, organ injured, management protocol and mortalities were comparable to standard literature.

Conclusion: Pediatric trauma is a neglected topic in developing nations due to absence of infrastructure and trained personnel. The high incidence illustrates the need to have proper training programs and education in this stream.

Blunt injuries are a common referral to any pediatric surgical emergency. Worldwide pediatric trauma accounts for 1.5 million injuries. Almost 90 percent of all trauma impacts are blunt in nature [1,2]. The head and extremity trauma account for majorities of all blunt injuries [1]. Abdominal blunt traumais a special concern due to their widespread and variable presentation and differing outcomes. The pediatric population are way different from their adult counterparts with regards to the body impact suffered from a similar trauma [3-5]. Children have poorly developed musculoskeletal system and the abdominal organs are in close proximity to each other. The abdominal wall is thin with less fat contents. Further, the small stature results in increased force per body surface area creating more damage to internal organs [5,6]. Evaluation and management protocols of blunt abdominal injuries in children have undergone drastic changes. Newer imaging modalities with better results obtained with conservative treatment have shifted the attention towards nonoperative modalities. The morbidities and mortalities should therefore be compared with caution. However, the trends have been partially limited in developing nations with constraints of infrastructure and proper trained health professional. Our study attempts to understand the trends of patient profile and management outlines in a tertiary care center of North West India.

Materials and Methods

The study was conducted in the Department of Pediatric Surgery, SMS Medical College Hospital, Jaipur. The study was retrospective, based on medical records of patients over a period of one year, from May 2015 to April 2016. All pediatric patients who were admitted with a provisional diagnosis of blunt trauma to the abdomen were included in the study. The maximum age limit was 18 years. All patients underwent evaluation and management by the same surgical team. The exclusion criteria included patients with penetrating injury to abdomen, patients with added head injuries needing neurosurgical care, patients with added extremity injury needing orthopedic care. The demography of these patients were studied with respect to different parameters as outlined next. The values obtained were analyzed and compared to available studies.

Results

The pediatric surgery emergency of SMS Medical college, Jaipur caters to all types of neonatal and pediatric emergency as per tertiary care protocols. Trauma in children accounts for a significant proportion of admitted children (10%). The total number of patients admitted in a span of one year was 288. The commonest age group was 3 to 6 years having 30% of all patients. More than half of all patients were less than 10 years of age (Table 1). Most of the children were referred from peripheral centers and district hospitals. This was expected as the department houses the only trauma center in the region (Table 2). The cause of injuries in children is different from those in adults. Direct injuries with impact over the abdomen are less common. Fall from height were noted in 45% of children, with motor vehicle accidents following it (Table 3). The patients underwent similar investigation protocols. Complete blood investigations were followed by imaging studies. X-ray, sonography and CT scan studies were performed as required. Based on the findings, single organ injury was found in more than half of all patients. Multi organ injuries are less common, in contrast to adult populations (Table 4). Liver was much more commonly injured than spleen and bowel (Table 5). This was the reason of better roles of conservative management in these patients. Nearly 61% of children were managed by non operative measures (Table 6). It is important that only 11 patients died, this accounts for 4% of total (Table 7). Patients with multi organ damage were the usual victims.

Table 1. Age distribution of patients admitted.

Age in years

No. of patients

Percentage

0-2

43

15%

3-6

86

30%

7-10

63

22%

11-14

58

20%

15-18

38

13%

Table 2. Distribution of patients referred to tertiary center.

Referral

Patients

percentage

Direct

46

16%

Indirect

242

84%

Table 3. Distribution of patients according to etiology of injury.

Etiology

Patients

Percentage

Fall from height

130

45%

Motor vehicle accident

107

37%

Direct trauma

51

18%

Table 4. Distribution of organ injuries based on number of internal organs injured.

Type of trauma

Patients

Percentage

Single organ

167

58%

Two organs

72

25%

Multi organs

49

17%

Table 5. Distribution of the internal organs commonly injured.

Organs involved

Patients

Percentage

Liver

143

50%

Spleen

58

20%

Bowel

96

58%

Pancreas

43

15%

Table 6. Management protocol

Management

Patients

Percentage

Conservative

176

61%

Surgical

112

39%

Table 7. Etiology of patients expired (MOD-multi organ damage)

Underlying cause

Expired Patients

N=11

Liver trauma

02

Splenic trauma

01

MOD

08

Discussion

A child is not a miniature adult. The principle applies to traumatology as well. The lesser body surface of area of children creates a higher impact for the same amount of force. Added to this, is the thin abdominal wall with poorly developed fat cushions [7-9]. Pediatric traumtology is a concern that should be managed with priority.Worldwide, 65% of all injury deaths results from unintentional injuries [10]. Approximately, 20000 pediatric patients die every year as a result of injuries [11, 12].

In developing nations, most injuries are observed in age groups of 13 to 18 years, particularly due to increased violence. This result is in contrast to our study where most trauma patients were less than 10 years of age. Motor vehicle accidents are the leading etiological factors causing abdominal blunt injuries [13,14]. However, this status does not hold true in most developing nations. In our study, children falling from height was the most common cause followed by motor vehicle accidents. The referral system has always been a concern in developing nations. The less number of trauma centers with poor inter center referrals result in delayed management in most cases. A large number of studies in children have quoted bowel injuries to be the most common injured internal organ followed by liver (52%) [15-17]. This might be related to the corresponding etiology in those cases. Rapid deceleration in car accidents cause compression injuries to the bowel [18]. In our study, we had maximum cases of liver contusions and laceration injuries. Spleen was less commonly injured in contrast to adults [19]. A recent study by Holmes et al. sought to follow the causes of failure of conservative management in trauma [1,2,20]. Around 85 to 90 % of children having liver damage could be managed by non-operative means [21]. The cause of failure included hemorrhage, shock, peritonitis among others [21,22]. Multi organ damage also necessitated surgical exploration in most cases.

Our study quotes resolution in 61% children with conservative measures alone. This might be related to the increased liver injuries in developing countries (50%). Patients treated nonoperatively had extensive monitoring with serial imaging and vitals statistics records. Standard conservative protocols of nasogastric suction, intravenous antibiotics and urine output monitoring was followed. Surgical repair was individualized with correction of etiology in most cases. One additional factor that we studied was the total mortality in one year. It is interesting that only 11 patients out of 288 died in this duration. Patients with severe multi organ damage with poor vitals were the usual victims.

Conclusion

Pediatric trauma derives special concern, not only for its subtle presentations but also for the specialized skills that it warrants in healthcare providers. Proper judgement, clinical evaluation and good imaging studies go a long way in proper diagnosis and prevention of unwanted surgeries.